What happens in electroshock therapy?

March 19, 1999

Dear Cecil:

My roommates and I are having an argument about electroshock therapy after watching Jack in One Flew Over the Cuckoo's Nest. What actually happens when someone gets zapped through the brain? Jack convulses for a number of seconds after he gets zapped, but one of my roommates contends that would not actually happen and there would be no convulsions after the initial shock (i.e., after the electrodes are removed). Can you give us the Dope?

— S.L. Keast, via the Internet

Cecil replies:

This is the most interesting thing you can think of to ask about electroshock? Whether it makes the patient twitch? Come on, what you really want to know is: (1) What is electroshock supposed to accomplish, anyway? and (2) You mean they're still doing it? (Answer: You'd better believe it.) But don't worry, we'll delve into the question of twitching, too.

Electroshock, more formally known as electroconvulsive therapy or ECT, was one of four radical techniques introduced in the 1930s to treat mental illness. (We learn this from Elliot S. Valenstein's Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness, which I recommend to anybody who thinks medicine is a science.) Besides electroshock there was lobotomy, insulin coma therapy, and metrazol convulsion therapy. Electroshock is the only one still in common use.

The idea behind "shock treatment," whether chemical or electrical, was to trigger a grand mal epileptic seizure. For ECT the patient was placed on a gurney and electrodes were applied to the temples or other points on the skull. In the early days a stiff jolt of house current was applied without further ado, and the patient went into convulsions lasting a minute or so. The spasms were sometimes violent and in about 1 percent of cases the patient suffered a broken bone or dislocation. (Broken bones were more common in metrazol therapy, causing many doctors to favor ECT.) In later years doctors began using anesthetics to knock the patient out plus a muscle relaxant to eliminate injuries. So to answer your question, patients twitched big time in the old days but relatively little now.

Although no one knew why (there were plenty of wacky theories), convulsions often produced a marked improvement in patients with severe mental illness — schizophrenics became lucid, for example. But the improvement was usually temporary, and the patient had to be shocked again. Six to 20 times over a period of weeks was typical, but the medical literature tells of one patient who was shocked five times a day, and another who was shocked 200 times in a year.

Shock treatment and lobotomy went into decline when antischizophrenic drugs were introduced in the 1950s, and drugs remain the preferred therapy today. But ECT has found its niche in the treatment of patients with major depression for whom drugs are ineffective or otherwise inadvisable. Some argue that for certain conditions it should be the first line of treatment.

The whole thing sounds barbaric, though I suppose this might be said of a lot of medical procedures. ("Babs, do you realize surgeons slice people open with knives and cut out their INTERNAL ORGANS??!!") Valenstein recalls a ward full of patients undergoing insulin coma therapy in 1950 who were drooling, twitching, grasping, shouting — a vision of hell. ECT is civilized by comparison. Still, there can be serious side effects and complications, ranging from protracted seizures and cardiac arrhythmia to confusion and amnesia. Although proponents argue that nowadays ECT is safe and scientific, there's no denying that inducing an epileptic seizure is a drastic procedure, and the main reason to undertake it is to help a patient who otherwise seems doomed.